Patient safety measurement tools used in nursing homes: a systematic literature review

Table. 1 presents the detailed characteristics of the 25 studies included in this systematic review. The NHSPSC and the Hospital Survey on Patient Safety Culture (HSOPSC) were used in 10 [11‐13, 15, 25‐30] and nine studies [21, 22, 31‐37], respectively. In addition, the NHSPSC-China, Safety Attitudes Questionnaire (SAQ), Safety Attitudes Questionnaire in a Skilled Nursing Facility (SAQ-SNF), Safety Attitudes Questionnaire–Ambulatory Version (SAQ-AV), and Modified Stanford Patient Safety Culture Survey Instrument (MSI) were used in one study each. Of the 25 studies, 16 were conducted in the US [11‐13, 15, 21, 22, 25, 27‐29, 33‐38], five in Norway [16, 30, 31, 39, 40] and the rest in France [26], China [32], the Netherlands [41], and Canada [42]. Most were quantitative studies, and there was one mixed study [42]. With regard to the participants, one study included long-stay nursing home residents with dementia [29], five studies targeted or included administrators [12, 15, 27, 34, 36], and the rest were conducted among facility staff working at nursing homes (registered nurses [RNs], certified nursing assistant [CNAs], nurse aides, direct care staff, and support staff). Minimal variation was noticed in the quality of the studies assessed using CCAT, with scores ranging from 36 (36/40, 90%) to 40 (40/40, 100%) out of a total of 40 (100%) points.

As shown in Table. 2, all the tools used in the selected studies were analyzed to assess whether the PSC elements—based on the elements included in the HSOPSC version 1.0—were met. The results revealed that there was no “frequency of reported incidents” in the NHSPSC; thus, “procedure compliance” was added. The SAQ tool did not have “communication openness,” “feedback and communication on errors,” “non-punitive response to errors,” “organizational learning,” “employee placement,” “transition and transition,” or “overall awareness of safety;” instead, it measured “job satisfaction,” “working conditions,” and “stress recognition.” The MSI tool consists of seven areas, and compared to the HSOPSC, “Management expectations and actions promoting patient safety” and “Overall perceptions of safety” are included. In addition, more emphasis is placed on safety such as “Perceived State of Safety” and “Senior Leadership Support for Safety.“ Overall, factor 3 of “Teamwork within units,“ factor 8 of “Teamwork across units,“ and factor 10 of “Management support for resident safety” were included in all tools, except for the MSI tool, while factor 6 of “Management expectations and actions promoting patient safety” was included in all tools. On the other hand, factor 11 of “Frequency of events reported” was not included in other tools except for the HSOPSC tool. Its Cronbach’s alpha reliability was reported to range between 0.7 and 0.90.

The PSC scores of nursing homes and hospitals differed slightly in terms of their subdomains, although most studies reported that nursing home scores were low [22, 28, 34, 36, 37]. However, one study reported that nursing homes also had higher scores than hospitals in some domains [28]. The PSC score was higher for RNs and CNAs in hospitals with low turnover rates [15]. While each increase in the overall positive response rate to PSC reported a decrease in medical defects (p = .001), proven complaints (p = .004), and fines (p = .059), there was an increase in the probability of being assigned a 4- or 5-star quality rating [12]. However, studies using the NHSPSC reported no sub-factors significantly associated with 5-star ratings [11]. People living with dementia in the nursing home group had a lower risk of in-hospital death, as their openness to communication regarding their PSC scores was higher [29]. The results reveal that higher PSC scores among CNAs are reflected by patients’ falls, for which modulated restraint use was reported [21]. In addition, increasing age and job position were associated with significantly higher mean scores for patient safety factors (teamwork climate, safety climate, job satisfaction, and working conditions) [40].

Considering the factors influencing nurses in terms of PSC, the PSC questionnaires reveal that the scores of CNAs were lower than those of RNs [41], while nurse managers reported higher scores than staff nurses [35, 36]. Licensed nurses employed in government-run establishments had significantly lower awareness of a positive safety culture than did nurses employed in nonprofit organizations [35]. RNs, licensed practical nurses, and nurse management/supervisors received the highest ratings for quality of collaboration and communication (very high), whereas nurse practitioners and physician assistants received the lowest ratings (range: 2.5–2.9) [38].

As shown in Table. 3, factors affecting patient safety included transformational leadership, job demands, job resources [30], facility ownership (p < .001), facility scale (p < .001), reporting management (p < .001) [40], being an integrated care institution or not (p = .006), frequency of concern about patient safety (p = .001), occurrence of adverse events in departments (p = .001), and a punitive atmosphere [32]. One study reported a positive correlation between teamwork climate, job satisfaction, perceptions of management, safety climate, and working conditions [37]. In this study, the explanatory power was 42.7%, with staffing and communication openness being significant predictors [31].